Bedside Teaching

Hospitalist as Teacher: Teaching Venous Thromboembolism Management in the Clinical Setting

The following teaching pearls are used by SHM members to teach VTE prophylaxis and management to residents and students. Submit your own to: vte@hospitalmedicine.org.

“I hand out laminated pocket cards to the team on the first day. On the front is our standardized risk assessment for VTE. On the back is a menu of appropriate VTE prophylaxis options. During the first week of every month I give a dedicated lecture to the team specifically focusing on the risk of VTE in the hospitalized medical patient and the importance of prophylaxis. I also check every admission or transfer order written by my team to make sure that VTE prophylaxis is addressed – if it’s not addressed I consider this a prime teaching moment and immediately page the person who wrote the orders.”

–Val Akopov, MD
Emory University School of Medicine

“I check medication orders on all patients via computer from my office or home prior to walk rounds and attending rounds. I identify specific patients who have not received adequate VTE prophylaxis to highlight that adequate evidence based VTE prophylaxis is still underutilized on the medical service. I emphasize that our role as physicians includes directing therapy against predictable complications of serious illness, that all hospitalized patients, both medical and surgical, should be assessed for VTE risk, and that VTE prophylaxis is cost effective. In general, the “sick, old, and surgical patients” benefit. However, I use a simple point system based on the March 2005 NEJM study reported by Sam Goldhaber et al:
Cancer 3 points
Prior VTE 3 points
Hypercoagulable state 3 points
Major surgery 2 points
Advanced Age 1 point
Obesity 1 point
Bedrest (>12 hours) 1 point
HRT or OCP 1 point
Increased VTE risk is defined as 4 or more points and daily assessments should be performed on patients who do not initially receive VTE prophylaxis. The main point I make is to think about VTE prophylaxis and to keep thinking about it for patients likely to remain in the hospital for 4 days or days or longer (PREVENT Trial)

-Sylvia McKean, MD
Brigham and Women’s Hospital

“During the month I go over an anecdote of how a patient acquired DVT in the hospital. I stress ‘needlessness’ – death or suffering, needless expense. This “awareness moment” is a good time to communicate how often we fail to use DVT prophylaxis in the hospital, how often our inpatients acquire VTE, and what performance improvements our system has made to reduce that number. Time permitting this is also a good time to teach how individual physicians and hospital processes interact to generate an outcome, and how hospitalists could use cycles of PDSA changes to improve hospital performance. At the end of the discussion I come back to the patient anecdote and try to personalize it – if this had been your grandmother would you consider this outcome acceptable? Then I hand out the laminated risk assessment cards.

-Jason Stein, MD
Emory University School of Medicine

“I make it clear at the beginning of the month that the Assessment and Plan of every H&P and progress note written by a resident or student must specifically address VTE Prophylaxis and articulate the plan. I encourage my residents to finish each note with a section called ‘Prophylaxis’ in which they also address indications and management plans for stress ulcer, VTE, decubitus ulcer, aspiration, and fall prophylaxis.”